Inspection on 17/11/05 for Eastcroft

This inspection was carried out on 17th November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Eastcroft 20/03/07

Eastcroft 24/08/05

Eastcroft 27/10/04

Eastcroft 30/06/04

Similar services:

The Shelley

Thorndene

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Eastcroft Woodmansterne Lane Banstead Surrey SM7 3EX Lead Inspector Pat Collins Unannounced Inspection 17th November 2005 8:45 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Eastcroft DS0000013317.V265575.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Eastcroft DS0000013317.V265575.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Eastcroft Address Woodmansterne Lane Banstead Surrey SM7 3EX Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01737 357962 Mr Ioannis Andreou Mrs Soteroula Andreou Mr Ioannis Andreou Care Home 20 Category(ies) of Dementia - over 65 years of age (20), Old age, registration, with number not falling within any other category (20), of places Physical disability over 65 years of age (8), Sensory Impairment over 65 years of age (3) Eastcroft DS0000013317.V265575.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Of the 20 (twenty) service users accommodated up to 20 (twenty) may fall within the category DE(E), dementia over 65 years of age Of the 20 (twenty) service users accommodated within categories DE(E) or OP up to 8 (eight) service users may also fall within category PD(E) Physical Disability over 65 years of age. Of the 20 (twenty) service users accommodated within categories DE(E) or OP up to 3 service users may also fall within category SI(E) sensory impairment- over 65 years of age. 24th August 2005 3. Date of last inspection Brief Description of the Service: Eastcroft is a care home providing nursing care for older people. Service provision includes dementia care and care of older people with physical disabilities and sensory impairment. The home is in private ownership and managed by the provider. The building is a large, detached property with car parking facilities, situated in a quiet residential area. Banstead village is within walking distance where there is a wide range of shops and other community amenities. Communal sitting and dining facilities are on the ground floor. These areas are tastefully decorated and comfortably furnished. The bedroom accommodation is arranged on the ground and first floor, accessible by passenger lift. The home has 16 single bedrooms and two shared bedrooms with en-suite facilities. There is an attractive, enclosed garden to the rear of the premises. Eastcroft DS0000013317.V265575.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place in one half day, commencing at 08.45 hours and concluding at 12.15hrs. The provider/ manager was present for part of the inspection. The nurse in charge competently represented the provider in his absence. The inspector spoke in some depth with two service users and was introduced and conversed with eight service users and three visitors. All staff on duty received opportunity to express their views about the home. A partial tour of the premises was conducted which entailed direct observation of communal facilities and of three bedrooms. Records were sampled as part of the inspection process. Six comment cards were received following the inspection from relatives and visitors and this information formed part of the inspection process. The inspector would like to thank the home’s management, staff team, service users and visitors for their hospitality and cooperation on the day of the inspection. What the service does well: Individual service users spoke well of their care. They considered their needs to be met and enjoyed positive relationships with staff. Staff were observed comforting a service user who had recently been admitted who was taking time to adjust to her new circumstances. Eastcroft has a committed and experienced staff team and an ongoing staff training and development programme. The provider/ manager and staff on duty evidently knew the service users well. Knowledge and understanding of service users’ individual needs was well demonstrated. The manager and staff were friendly, caring and professional in their approach towards service users and visitors. Service users benefited from an individualised care approach based on assessed needs being recorded in care plans which were reviewed monthly. Observation made of care practice evidenced that service users’ dignity and privacy was well respected. There was evidence of good teamwork by staff. A suitably stimulating environment was evident and an activity programme provided. Interaction between staff and service users was frequent and age appropriate. An employee had delegated responsibilities for coordinating the home’s activities programme. This employee was supernumerary to staffing levels for the delivery of nursing and personal care. It was positive to note provision of a minibus for service users to be offered choice of going out in fine weather. Written expressions of satisfaction with the home’s management and standards of care from relatives and service users representatives were publicly displayed. Information obtained from visitors and relatives after the Eastcroft DS0000013317.V265575.R01.S.doc Version 5.0 Page 6 inspection indicated a high level of satisfaction with the home’s operation and standards of care. It was said that management ensured service users families/ representative were informed of significant matters and appropriately consulted on decisions about care. A sample of comments received from visitors/relatives were “ the proprietors and staff at Eastcroft seem to be caring and try to make their residents as comfortable as possible considering their various needs”. “ It is comforting to know my relative is so well cared for”. “Eastcroft is a friendly home, food is satisfactory, staff are willing and try and make my relative very comfortable”. “ Nursing staff are excellent and very friendly in the morning, the afternoon staff are sometimes not so friendly. Hygiene and care is very good – no nasty smells”. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Eastcroft DS0000013317.V265575.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Eastcroft DS0000013317.V265575.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not assessed on this occasion. When last inspected in August 2005 the home was observed to be operating effectively in respect of standards 1 to 5. Standard 6 is not applicable to this home. EVIDENCE: Eastcroft DS0000013317.V265575.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 Health and social care needs appeared effectively met. Care plans were in need of further development. This had been identified through internal auditing systems and work in this area was in progress. EVIDENCE: The care plans sampled were overall based on comprehensive assessment of needs. Systems were in place for regular review of service users’ needs. Encouragement and support was given to service users to enable them to maximise independence within individual capacities. It was positive to observe work in progress for further developing the home’s care documentation and care planning processes to enhance the person-centred approach to care in the home. It was noted that existing care plans had been formulated from the perspective of service users. Personal preferences, likes and dislikes had been identified and recorded in the care records and were known by staff. Service users were registered with a GP practice, usually the local medical practice next door to the home. Records of ophthalmic, dental and chiropody needs being met were viewed. General practitioners and a diabetic nurse Eastcroft DS0000013317.V265575.R01.S.doc Version 5.0 Page 10 specialist visited regularly and records retained of their professional advice and treatment. Areas of discussion included the need to ensure that at all times admission procedures include pressure sore risk assessments carried out and for regular review. This was not evident from the file sampled relating to a service user with a pressure sore present on admission. Also for care plans to clearly demonstrate pressure sore prevention strategies that were evidently in place but not fully recorded. Service users care documentation must include records of pressure relieving equipment used for each individual. It was noted that a risk assessment for prevention of pressure sores had not been reviewed as expected given the previously high - risk score. Attention was also required to pressure sore treatment records to ensure wound classification is recorded following wound assessment and accurately reflects all treatment. Attention was drawn to the requirement for notification to the Commission of all pressure sores of grade ii and over, present on admission or acquired in the home. Eastcroft DS0000013317.V265575.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not inspected on this occasion. At the time of the last inspection in August 2005 standards 12 to 15 were effectively met. It was demonstrated that service users experienced a good quality lifestyle at that time. EVIDENCE: Eastcroft DS0000013317.V265575.R01.S.doc Version 5.0 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not inspected on this occasion. At the time of the last inspection in August 2005 standards 16 to 18 were effectively met. At that time it was demonstrated that service users were well protected by the home’s policies and procedures including the complaint procedure. EVIDENCE: Eastcroft DS0000013317.V265575.R01.S.doc Version 5.0 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 The home environment was tastefully decorated and appropriately and comfortably furnished and to a high standard, affording those who live at the home with safe, comfortable surroundings. EVIDENCE: Observations confirmed an excellent standard of internal and external maintenance. The home was clean and hygienic throughout and odour control was also excellent. Service users benefited from provision of comfortable, furnishings and suitable equipment in pleasant, attractively decorated surroundings. Effort had been made when furnishing the home to provide appropriate cues to aid orientation, recognition and way finding. This afforded a positive environment for people with dementia and short term memory loss. Eastcroft DS0000013317.V265575.R01.S.doc Version 5.0 Page 14 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 29 Consultation with staff confirmed that good practice recruitment procedures continued to operate as demonstrated at the time of the last inspection in August 2005. Attention was drawn to the change last year to practices relating to CRB staff Disclosures that are no longer portable/transferable between employers. EVIDENCE: When inspecting standards 27, 28 and 30 in August 2005 the inspector concluded that service users were supported by competent, suitably trained staff that demonstrated good awareness of service users needs. Observations at the time of this inspection confirmed good practice care delivery and positive relationships between service users and staff. Discussions with staff confirmed good practice staff recruitment and vetting procedures were overall operation though attention drawn to changes regarding CRB Disclosures. These are no longer portable therefore care homes must apply for new CRB Disclosures and obtain a POVA check for new staff and staff employed in other care services starting on or after 26th July 2004. The provider confirmed that a new CRB Disclosure would be obtained for a staff nurse employed part – time on the basis of a CRB Disclosure obtained by his employer where he works full – time. Eastcroft DS0000013317.V265575.R01.S.doc Version 5.0 Page 15 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 37 and 38 Observations concluded that the home’s management provided strong leadership, guidance and direction to the staff team. This ensured that service users received consistent, good quality care. Record keeping, care practices and management arrangements promoted and safeguarded the health, safety and welfare of service users. EVIDENCE: The provider/manager is a dual registered qualified nurse who has attained a management qualification in care at NVQ level 4 and also the registered managers award qualification. The management style was observed to be open and supportive of staff whilst promoting high standards. Eastcroft DS0000013317.V265575.R01.S.doc Version 5.0 Page 16 The home’s staff training and development programme included training in first aid, moving and handling, fire safety, health and safety and infection control. The provider confirmed plans for distance learning refresher training for staff in health and safety and infection control. Discussed was the importance of instituting regular updated training sessions for nurses on wound care. Statutory records were in place and well constructed. Attention was drawn to the need to ensure confidential storage of accident records, ensuring these can be easily cross - referenced to files. This should not adversely affect existing systems for accident monitoring. Eastcroft DS0000013317.V265575.R01.S.doc Version 5.0 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x x x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 x 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 x COMPLAINTS AND PROTECTION Standard No Score 16 x 17 x 18 x 3 x x x x x x x STAFFING Standard No Score 27 x 28 x 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x 3 x x x x 3 3 Eastcroft DS0000013317.V265575.R01.S.doc Version 5.0 Page 18 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP77 Regulation 12(1) (a)(b) 13(4)(c) Requirement For pressure sore risk assessments to be routinely carried out on admission and be subject to periodic review and in response to change in needs. Pressure sore prevention strategies where relevant must be recorded in care plans and pressure relieving equipment documented. For the staff recruitment procedures to include a POVA check for staff for each separate care position started on or after 26th July 2004. Timescale for action 17/12/05 2 OP2929 19(1) (a)(b) 24/11/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Eastcroft DS0000013317.V265575.R01.S.doc Version 5.0 Page 19 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Eastcroft DS0000013317.V265575.R01.S.doc Version 5.0 Page 20 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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